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The vast majority of patients are usually completely satisfied with their medical care and are grateful to their doctor. However, in some cases, problems can occur, and you need to know what steps you can take if you are unhappy or dissatisfied with the outcome of your treatment.

In the first instance, you should try to resolve the problem as quickly as possible. Talk to the doctor or the hospital administration to try and settle matters at the earliest, especially with regard to minor complaints ( such as rude staff, telephone calls not being returned or unpalatable hospital food). Most complaints originate due to seemingly trivial problems.

If however, if you have a serious complaint about your medical care, and if you are convinced that your doctor has been negligent, you can take appropriate action. However, do remember that just because the outcome has not been satisfactory ( for example, a patient dies during surgery) , it does not necessarily mean that the doctor has been negligent or irresponsible! There are many reasons why patients do not do as well as expected; after all, medicine is an inexact science which deals with many biological variables that are beyond anyone's control. Consequently, in spite of the best care, a patient may die or his condition may become worse.

There are many avenues open to you to get redressal, and you may choose any or all of them. For instance, you can make a complaint to the local professional medical body, usually the state medical council. The appropriate medical council can punish the doctor: for example, by removing his name from the medical register, if he has been found guilty of serious professional misconduct, either permanently, or for a specified period, so that he can no longer practice medicine.

Before taking legal action, you should carefully consider all the implications and repercussions. The process can be a very long and expensive one. You must also ascertain precisely what you want to achieve by initiating litigation. Do you merely want an apology from the doctor? Are you angry with the doctor because you feel he was careless and you want to seek revenge? Do you want to expose the doctor's incompetence to the public to protect other patients? Do you want monetary compensation? While all or any of these objectives may provide sufficient reason to go to court, do remember that medical malpractice lawsuits are powerful double-edged weapons which should be used only as a last resort. Not only can such lawsuits damage a good doctor's reputation, they can also create a lot of tension between patients and doctors in general. Let me point out, in this context, that unnecessary and excessive medical litigation has led to the regrettable situation in which American medicine finds itself today, in which both doctors and patients have become losers.

Our website is the global face of our clinic. I take it very seriously, because we treat patients from all over the world and our website is the first point of contact for all our patients. It’s crucial to our success and our webmaster plays a key role in our business !

I need a webmaster who understands the importance of a website in our business – someone who does not see himself as just a web designer, but rather as a business partner who can help us to grow.

Here’s my wish list for a perfect web designer/ webmaster.

• His competence and efficiency is taken for granted – but I am a premium client, and want to be treated as one. I am willing to pay the additional premium, and I want someone who understands the importance of keeping me happy !
• I want someone who will extend my horizons – someone who will push me to explore new digital technologies and will keep me on my toes. I’d like someone who comes up with new ideas – and encourages me to explore them.
• I want someone who understands that I am a professional and that I am investing my hard earned money in my website – someone who will do their best to maximize my ROI.
• I want someone who makes me happy to work with him – someone who is willing to listen to my suggestions as to what he can do to improve the quality of services he provides to me.
• I expect him to grow and keep up with the new technologies – so that as he grows , so will our website ! I want someone who is willing to partner with other web companies, who have complementary skill sets, so he can provide a more exciting range of services.
• I want someone who is willing to put in the effort to be a “one-stop shop” for me, so I do not have to talk to many service providers about my digital presence
• I need quick replies and a fast turnaround time. If my website is down , this is an emergency – and I need a quick response and a fast fix ! I want someone who will monitor my website uptime – and will fix problems if they arise by talking to my web hosting company.
• I want someone who will take a proactive role in helping me to reach out to more patients ! He will teach me about Web 2.0; social media; facebook ads and google adwords, so I can explore these additional avenues.
• I want someone who has a ticketing system to log in complaints – and provide me a with a timeline in which they will be fixed !
• I want someone who is customer centric. As a doctor, I am in the service business and am intensely focused on what I can do to help my patients. I want someone who treats me exactly the way I treat my patients – with respect ; and the assurance that I will get the full attention of a consummate professional, who will give me value for money !

Most doctors get put off by patients who complain and most doctors will either ignore these patients – or fire them ! While I’d rather have smiling and happy patients as well , I also believe that every complaint is a gift – it’s a chance to learn and improve. In fact, we actively encourage our patients to provide us with feedback – and both compliments and complaints are welcome . Compliments give us a high and tell us we are doing a good job. Complaints remind us that we can do better !

As a doctor, I am focused on providing high quality medical care to my patients. However, I also run a clinic, and I may not see some basic problems ( which are easy to fix) unless someone takes the trouble to point them out to me !

Most patients are quite reluctant to complain to their doctor. For one, most are respectful and are quite grateful for the medical attention and care they are getting. They feel they should not be wasting their doctor’s time on minor trifles. Also, many are worried that if they complain, the doctor may get upset and may not provide them with good medical care. This is why most patients are docile and compliant in the clinic. However, when they leave the clinic, they will then openly criticize the doctor – an unhelpful approach , which does not help either the doctor or the patient !

I encourage patients to provide feedback to doctors – after all, if there are problems and you do not tell us about them, how will we improve ? However, not all complaints are helpful, so if you do want to provide constructive complaints, you must learn the right way of doing so. There’s no point in complaining when you are angry and upset. This might seem counter-intuitive, but this is the time when you are likely to say things you may regret later ! It’s best to complain when you are cool and collected – and when your doctor also has time to sit and listen to your feedback. Providing written feedback is also useful, if you are willing to take the time and
trouble . However, complaining behind the doctor’s back is very unhelpful !

Just like patients need to learn how to complain, doctors also need to learn how to listen to their patient’s complaints in a mature fashion. This is a useful skill for all doctors to acquire. Remember that for every one patient who complaints, ten will get upset – but rather than take the time to complain, will just walk out of your practice to your next door competitor !

Complaints should not be ignored – they need to be managed. Your patient is your customer, and you owe him a duty of service ! When dealing with angry unhappy patients, it’s very easy for problems to escalate , and when tempers are lost, everyone stands to lose. Often doctors do not have the maturity to listen calmly to a patient’s complaints. Many will take a complaint as a personal affront – and will feel the patient is disparaging them . Others may even get incensed – “ How dare a patient criticize me ! After all, I am a senior , respected and experienced doctor who knows much more than he does ! “ If you do not manage angry patients well, this will end up hurting you in the long run. Angry patients may end up suing a doctor – especially when they feel the doctor has been uncaring or rude.

Listen patiently and respectfully. It’s true that not all complaints are valid and not all problems can be fixed, but giving the upset patient a patient hearing can make a world of a difference !
When a patient complains, rather than getting angry or defensive, a useful acronym to remember is LEAD - L = Listen ; E= Empathise ; A= Act ; D= Document. When do patients complain ? When there is a mismatch between expectations and reality. This is why it’s so important to be honest and transparent with your patients.

I always tell my patients – If you are happy with us, please tell the world ! If you are not happy with us, please tell us, so we can fix the problem !

I had just finished seeing a patient who came to me from Bangalore for IVF treatment , and before leaving the room, he turned around and said - " Thank you so much for taking the time to listen to us so patiently ! "

I was flummoxed ! After all, isn't listening to a patient a part of the doctor's job description ? Why was he thanking me for doing something which is so routine and mundane ?

When I asked my next patient why I was being thanked, he said - That's because you are so different from most other doctors, doc ! Most doctors just rush like automatons through a long line of patients. It's like they are just processing an assembly line of people - and they have 7 minutes in which to listen to you . They are always rushed and harassed - and it's very hard to have a decent convesration with them. Most of them are focused on the medical issue at hand - while some only speak medicalese, so it's hard to make sense of what they are saying. It's a pleasure to meet a doctor who can have an intelligent conversation and is interested in me as a person.

I love talking to my patients ! They come from all over the world and have interesting stories to share ! I am naturally curious and love learning new stuff. Doctors tend to get very inbred and talking shop to other doctors can get very boring and monotonous. Listening to patients talk about their professions helps me to get a better understanding of what's happening in the rest of the world and broadens my horizons. Patients are smart and intelligent and are happy to talk to their doctors . They are a great source of intelligence - and I am not just talking about hot stock tips here ! They teach me about what's happening in the online world and help me to keep my website ( and my wits) sharp and clear !

Patients have a lot to teach doctors - I just wished doctors opened their hearts and minds and took the time to listen and learn ! Doctors need to be reminded that they are uniquely privileged in being given a ringside view to a person's innermost desires and struggles when their patients are battling with some of the life's most difficult moments. A smart doctor can learn a lot from his patients - both how to live and how to die when the time comes - he just needs to be willing to do so !

HOW I IMPROVED MY VITRIFICATION TECHNIQUE !

SAIPRASAD GUNDETI, SENIOR EMBRYOLOGIST, MALPANI INFERTILITY CLINIC PVT. LTD.

Vitrification involves freezing the embryo about 600 times faster than ever before. This ultrarapid process is so fast that it literally allows no time for intracellular ice to form. As a result, vitrification avoids trauma to the embryo.
In conventional (slow) freezing, 20-30% of embryos do not survive the freeze-thaw, and those that do survive have less than half the likelihood of generating a pregnancy as do fresh embryos. In contrast, vitrified embryos have a better than 95% freeze-thaw survival rate, and a pregnancy generating potential that is comparable to fresh embryos.
Vitrification is now regarded as potential alternative to conventional (slow)freezing.

Major advantages of Vitrifiction over Slow freezing are :

• Its prevents ice crystal formation within the cells, which can damage the embryo.
• It eliminates use of expensive freezing unit(required for slow freezing).
• High survival rate post thaw.
• High pregnancy rate following transfer of thawed vitrified embryos.

At Malpani infertility clinic, we have been using vitrification for a number of years to cryopreserve both embryos and eggs. When it comes to embryo cryopreservation, we freeze all stages of embryos i.e. Day 1, Day 2, Day 3, Day 5 and Day 6.

Steep Learning Curve :

To avoid embryo exposure to high concentrations of toxic cryoprotectants for extended periods, vitrification protocols generally require that embryos remain in the vitrification solution for a fixed time. This can be difficult, especially since vitrification technique have an extensive learning curve before the technique is mastered. Even with practice, one may not be able to quickly pick up embryos and vitrify within the time required.

Therefore it's critical that we determine the length of time the embryos can safely reside in vitrification solution, so that we don't overexpose embryos to toxic cryoprotectants, which can kill them or lead to very poor post thaw survival.

How difficult is it to master the technique?

Vitrification technique is a difficult art to master:

1. Due to high concentrations of cryoprotectants, vitrification medium is very viscous. High viscocity makes it very difficult to handle embryos, while they are in the medium. Needs lot of practice in order to get efficient.
2. One needs to be quick while handling embryos in vitrification medium, as long exposure of embryos to cryoprotectants can kill embryos or lead to poor survival rate post thaw.
3. Loading embryos onto cryolock is the most difficult part. It requires lot of practice. Improper loading can also affect the survival rate.
4. Thawing procedure (called Vitrification Warming) is as important as the Freezing. Improper thawing may lead to poor survival. So one needs to thaw embryos carefully in order to ensure good survival of embryos.

How do I vitrify your embryos and eggs?

VITRIFICATION FREEZING

We use Quinn's Vitrification Medium at our centre for freezing Embryos and Eggs.
Quinn's Vitrification Medium contains 2 media, "Equilibration Medium" and "Vitrification Medium"

Equilibration Medium contains Base Medium(Hepes buffered Medium) + 7.5 % ethylene glycol + 7.5 % DMSO (Dymethyle sulfoxide) + 20 % Protein supplement

Vitrification Medium contains Base Medium(Hepes buffered Medium) + 7.5 % ethylene glycol + 7.5 % DMSO (Dymethyle sulfoxide) + 0.5 M Sucrose + 20 % Protein supplement

Preparation of Vitrification Dish :

Place 1 drop of 0.1 ml of "Equilibration Medium" and 4 drops each of 0.05 ml of "Vitrification Medium" as shown in the figure.

The entire Freezing procedure is performed at room temperature.

We need to leave the Petri dish in the workstation for 15 min, for the medium to recover to room temperature.

Equilibration

• Place embryos or eggs to vitrify in equilibration medium. (This will be number of embryos or eggs that will be placed on 1 cryolock). We don't put more than 3 embryos or eggs on 1 cryolock.
• Once embryos or eggs are placed in Equilibration Medium, they spontaneously begin to shrink . This is when the intracellular water comes out.

Picture of shrunken embryo, after placing it in the equilibration drop.

• The shrunken embryo or egg will gradually recover back to its original size. This takes approximately 7 to 8 minutes. This may be less or more than 7 to 8 minutes in some embryos and eggs.

Vitrification

• Once the embryo or Egg recovers back to its original Size, its ready to be vitrified. I generally vitrify the embryo or egg once it recovers to about 80% of its original size.
• Pick up the embryo or eggs from equilibration drop with a flexipet and place them in the 1st drop of vitrification medium.
• Once the embryo or egg is placed in the vitrification drop, it again starts shrinking. Keep the embryo or egg in the 1st vitrification drop for 10 sec. This is basically to get rid of Equilibration medium, which is carried along with the flexipet while transferring them from equilibration medium.
• While the embryo/egg is in the first drop of vitrification medium for 10 sec, rinse the flexipet by pipetting the vitrificaition medium to get rid of equilibration medium.
• After 10 sec, pick up the embryos/eggs from the 1st vitrification drop and transfer them to series of 3 drops of vitrification medium one after other.
• Quickly load the embryos onto cryolock with very little medium. Make sure to gently remove excess medium in case a bigger drop is made on the cryolock.
• immediately plunge the cryolock in Liquid Nitrogen. Now the embryos are vitrified.
• Slowly put the cap to the cryolock, while it is immersed in the liquid nitrogen.
• Put all the cryolocks in one visitube.
• Put the visitube into canister.

Vitrification Warming (thawing)

Quinn's vitrification warming medium contains 3 media, "Thawing Solution", "Dilution Solution" and "Washing Solution"

Thawing Solution (TS) contains Base media (Hepes buffered medium) + 1M Sucrose + 20% protein supplement.

Dilution Solution (DS) contains Base media (Hepes buffered medium) + 0.5M Sucrose + 20% protein supplement.

Dilution Solution (DS) contains Base media (Hepes buffered medium) + 20% protein supplement.

Preparation of dishes :

• Place a drop of 0.2 ml of Thawing solution (TS) in one dish as shown in the figure.
• Keep the dish for warming at 37 deg. C on a warming plate for about 15 min.
• Place 1 drop of 0.1 ml of Dilution Solution (DS) and 2 drops each of 0.2 ml of Washing solution in another dish as shown in the figure.
• Keep the dish at room temperature.

0.2 ml of Thawing Solution at 37 deg. C.

• Identify the cryolock (embryos we want to thaw) and put in the box containing Liquid Nitrogen.
• Remove the cap of cryolock, while it is immersed in Liquid nitrogen.
• Quickly submerge the cryolock tip into thawing solution under stereomicroscope view.
• The embryo will automatically dispel.
• Leave the dish at 37 deg. C for 1 minute.
• After 1 min, carefully collect the embryos from the thawing solution to Dilution Solution at room temperature making sure carrying forward minimal amount of thawing solution along with the embryos.
• After 3 min. pick up the embryos and transfer them to 1st washing solution. The embryos will recover back to its original size approx after 2 min.
• After 3 min. transfer the embryos to second washing solution.
• after 3 min transfer the embryos to culture dish.
• Incubate the embryos for 2 hours before transferring them to patient's uterus.

What mistakes can a beginner do while vitrifying, that can lead to a poor survival rate?

Preparation of vitrification dish

Mistake :

Placing only 1 drop of vitrification medium, trying to cut down on the amount of medium consumed.

Reasons :

• Using only 1 drop of Vitrification medium doesn't allow us to get rid of Equilibration medium before actually vitrifying the embryo/egg.
• The Equilibration Medium is not very effective when it comes to cryoprotecting , as compared to Vitrification Medium.

Solution :

• Use 4 drops of vitrification medium.
• Serially transfer embryos/eggs through the series of these 4 drops of vitrification medium. This allows us to get rid of the equilibration medium effectively.
• This will definitely ensure better survival rate.

Equilibration

Mistake :

• Keeping the embryos in Equilibration medium for a short period of period before transferring them to Vitrificaition medium.
• This happens when we rely on fixed time period for each medium.

Reasons :

• Once the embryo/egg is placed in Equilibration medium, it will shrink spontaneously and slowly recover back to its original size. The recovery period varies for different embryos.
• When we rely on fixed time period for e.g. 5 min in Equilibration medium, it may not be enough for the embryo/egg to recover to its original size.
• If we transfer the embryo/egg to vitrification medium before it recovers back to its original size, it doesn't vitrify properly, which leads to extremely poor survival rate post thaw.

Solution :

• Rather than relying on a fixed time, it's best to individualise the time, based on the shrinkage and recovery of each individual embryo/egg , to ensure better vitrification.
• The embryo/egg can take approximately 7 to 8 min. to recover back to its original size.
• In some embryos it can be less or more than 7 to 8 min.

Vitrification :

Mistake :

• Making a large drop of vitrification medium along with embryo/egg while loading it on cryolock.

Reasons :

• A large volume of vitrification medium on cryolock will not allow proper vitrification of the embryo/egg.
• If the embryo is not vitrified properly, it leads to poor survival.

Solution :

• Make a flat small droplet of vitrification medium.
• Even if the drop is large, get rid of the excess medium by aspirating it gently.
• An embryo placed in a minimal amount of vitrification medium on cryolock vitrifies perfectly.

Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !

Here's a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !

1. D&C ( dilatation and curettage) . This is a "minor" surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette
( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to "clean the uterus", thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.

2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor "improves" the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It's only in India that doctors use this technique for "treating" infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.

3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.

4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is - and will often reflexively treat men with what they think is an "abnormal sperm report". There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels - and doctors are quite happy to "fix" the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential - and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)

5. Treatment for genital tuberculosis. We are now seeing an "epidemic" of uterine TB in India - especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli - without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !

6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at www.drmalpani.com/torch.htm

7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that " you need just one sperm to fertilise an egg", it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer - and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low - its often that the sperm are functionally incompetent - and no amount of concentrating the good sperm or washing them is going to help !

8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it's being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It's true that a laparoscopy allows the doctor to also "find" adhesions and endometriosis, but making the diagnosis of this ( or "treating" them ) does not really improve the patient's fertility at all !

9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively "treat " this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary - and does not improve the patient's fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, "treating" the endo with meds just wastes the patient's time - something which most infertile patients cannot really afford to fritter away !

10. Operative laparoscopy for myomectomy and cystectomy. One problem with today's high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to "diagnose" small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has "reported" his "diagnosis", the patient often panics ! The doctor is happy to point out these abnormalities - and convinces the patients that it is these abnormalities which are the cause of her infertility - and that once these are "treated", she'll get a baby quickly ! What's worse is that it's easy to do the surgery with a laparoscopy ( which is just "minor surgery"), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What's worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests - and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests - and the truth is that some tests can actually be harmful !

The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !

The message is simple - if you have a medical problem, remember that Information Therapy is invaluable ! Please get a second opinion if you are unsure and confused. Send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !

A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )

How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.

Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.

There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.

1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level

Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images - we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.


Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.

As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.

The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.

The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !

If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.

If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.

The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).

For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !

Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I'll be happy to help !

For many IVF clinics, the patients which cause the most distress are the ones who are poor ovarian responders. These are patients who have poor ovarian reserve - and are often heartsink patients, because no matter what we do , it's very difficult to get them pregnant !

It is possible to get them to grow eggs and make embryos - and this actually makes the matter even more complex. This often creates false hopes - if I can make eggs and embryos, of course I can get pregnant ! All I need to do is to get the embryo to stick !

Unfortunately, there is no easy answer, and every patient needs to look into their own heart to resolve this personal quandary for themselves. While we are very happy to aggressively superovulate these patients, I feel using expensive and unproven treatments ( such as growth hormone injections , intravenous immunoglobulins and IV intralipds ) are difficult to justify !

What makes a complex situation even more confusing are the anecdotal success stories which litter the internet ! It's hard to separate the wheat from the chaff, and since hope springs eternal in the human breast, many patients are willing to "give it one more shot " !

From a medical point of view, using donor eggs is the most efficient way of solving the problem - with a very high success rate. Unfortunately, it's also the one solution which is hardest to come to terms with ! The question you need to ask yourself is simple - what's most important for me ? Do I want to propagate my own genes ? Or do I want to have a baby ?

Need help in making a decision ? Send me your medical details by filling in the free second opinion form and I'll be happy to guide you through your options, so you can make the best decision.

" On Sunday, the quasi-governmental organization, Quality Control of India, will introduce the accreditation process with the first stop of healthcare for most consumers: neighbourhood doctors. “Once the government passes the Clinical Establishments Act, it will be binding on all healthcare providers to seek accreditation,’’ said QCI secretary general Dr Giridhar Gyani.
How will Cliniq 21st help patients ? It will mean that a doctor with the brand has been attending continued medical education (CME) lectures, he or she will provide health checkups for his/her staff and the clinic will have minimum required emergency care equipment and the place will be fumigated once a week. “Once patients or their relatives see this Cliniq 21st board outside a doctor’s chamber or a clinic, they can expect a certain standard of treatment and infrastructure,” said Dr Ravi Wankhedkar of the Indian Medical Assocation’s state branch.

Cliniq 21st Must-Haves

Doctors must attend continued medical education of at least six credit hours every year (including 1/2 hour on emergency medication)
Clinics should be well lit and should have educative material
The staff should undergo health check-ups for communicable diseases at least once a year
All displays must be in two languages
Tariff cards should be published
A clinic must be fumigated once a week
Floor plan of the clinics should be available to patients and relatives
Doctors should maintain detailed records of their patients "

I am very excited that the government is making patient education compulsory for all clinics. This will help to empower patients with information and make medical therapy much more transparent and effective !

The commonest question patients will ask before starting an IVF cycle is - what are my chances of getting pregnant ?

While it's true that the chances of success do depend upon how good your IVF clinic is, it's also true that the chances do depend upon biological factors which are outside your control - the most important one of which is your age !

You can now use the Free IVF Predictor to estimate how good your chances of success are ! While you cannot do much about your age, you can improve your chances of success by choosing a world class IVF clinic !

While all IVF patients understand with their heads that not every IVF cycle results in success, in their heart of hearts, every patient expects to get pregnant every time they do IVF ! This is why the 2ww after the embryo transfer can be so nerve-wracking ! Am I pregnant or not ? Have the embryos implanted or not ? The suspense during the 2ww can be even worse than the pain of the IVF injections !

Most patients would love to have a test which will allow them to find out if they are pregnant immediately after the embryo transfer ! Have the embryos stuck or not ? Why can’t we do a pregnancy test and find out right now ? Even if I am not pregnant, at least it’s better to know than to be unsure.

To understand why patients ( and their doctors ) still have to suffer through a 2 week wait to find out the outcome of an IVF cycle, let’s look at the biological basis of pregnancy tests and how they work.

A pregnancy test measures the amount of beta hCG ( human chorionic gonadotropin) that is in your body. HCG is a hormone which is produced by the trophectoderm cells of the embryo. It is produced in detectable quantities only after the embryo implants. Since implantation occurs 3 - 8 days after the embryo transfer ( depending upon whether you have had a Day 3 transfer or a blastocyst transfer), this means that the HCG produced by your embryo will be first detectable in your bloodstream only after this time.

As your pregnancy progresses, the amount of hCG in your system will increase. At 10 days past ovulation ( DPO) , for example, the average woman has an hCG measurement of around 25 mIU. This amount doubles to 50 mIU at 12 days past ovulation, and then doubles again to 100 mIU at around two weeks past ovulation. Every woman’s body is different, and there’s a lot of variation in HCG levels from woman to woman !

Home pregnancy tests measure the level of HCG in urine. Different pregnancy tests have different levels of sensitivity which means if you use a home pregnancy test that is sensitive to 100 mIU, it will not tell you that you are pregnant if your level of hCG is only 75 mIU. These tests cannot measure a level lower than 25, so they do not become accurate until a few days after embryo implantation. A negative result before then is meaningless, since there would not be a high enough level of HCG to detect even if you were pregnant. If your test is negative, you should retest after 2 days. This is why taking a pregnancy test too early can lead to inaccurate results. I know it’s hard to wait those extra days and you may want to try much earlier. It’s fine to do this, but please don’t assume that a negative results means that you are not pregnant.
This is also why blood tests for HCG are much better than urine tests. Not only are they more reliable, accurate and sensitive, they also give the doctor a number which he can measure and monitor.

If blood tests are so sensitive, then why not do a blood test for HCG 1 week after the embryo transfer ? Unfortunately, doing a blood test for HCG so soon does not make any sense. This is because there will still be some HCG in your body as a result of the HCG trigger shot ( Choragon or Ovidrel) which the doctor gave you to trigger off ovulation 36 hours prior to egg collection. If you test too early, the test will always be positive, as this HCG will show up in the test and give rise to false hopes ! This is why the doctor needs to repeat the blood test for HCG after 48-72 hours. In a healthy pregnancy, the HCG levels will continue to rise. If they do not do so, this means this is not a viable pregnancy.

Finally, remember that you should do the test even if you bleed. Bleeding can sometimes occur during pregnancy as well – and just because you have had bleeding or spotting does not mean you are not pregnant !

Malpani Infertility Clinic have just launched India's first free phone service to educate infertile couples about infertility.

This innovative IVR ( interactive voice response) service called FertilityFactsFoneLine, powered by BolTell, walks patients through their treatment options, and helps to dispel many myths and misconceptions.

Best of all, it's free !

Try it out by dialling 08042658370 !

I am a full-time practising doctor and yet sometimes I believe that the medical profession is not always completely honest with patients.

Now, I am not talking about the rubbish which alternative medicine practitioners are selling about how the medical establishment is out to rip patients off with unnecessary surgery and exorbitantly priced drugs. And neither is it true that doctors will gang up on patients and refuse to testify against other doctors when a medical mishap occurs. I believe that most doctors are honest professionals who are doing their best to try to help their patients to get better.

The truth is far worse. Sadly, most doctors do not realise the harm they often end up inflicting on their patients. They mean well, but because they become arrogant and brainwashed as they get older, they often end up doing a major disservice to their patients !

Arrogant ? Brainwashed ? Aren't these harsh words ? Aren't doctors supposed to be intelligent hard-nosed professionals who practise medicine based on hard-core scientific evidence ? How can they be brainwashed ? And by whom ?

Doctors set so much store by what they have been taught by their teachers that they tend to stop thinking like scientists. They do not ask questions or think critically , and will often continue to worship holy cows, even when they should know better. Old habits die hard in the medical profession, and the process of medical education inculcates an attitude of " do what you are told" in medical students and residents, who are taught to respect and obey professors and experts , rather than challenge old paradigms or think "out of the box".

This also explains why doctors become arrogant over time. They become set in their ways ; their attitudes harden; they feel they know everything there is too know about their specialty; and they refuse to consider evidence which does not fit in with their established beliefs. They will often even be disrespectful towards their patients because they do not value their opinions or insights.

For a man with a hammer, everything looks like a nail - and this is as true for doctors as anyone else. Thus, for a cardiac surgeon, every narrowing on an angiogram is an indication for bypass surgery - even though there is no proof that this helps the asymptomatic patient even one bit ! Why don't doctors learn from clinical experience ? This is because they fall victims to the fallacy of believing in the self-fulfilling prophecy that bypass surgery helps patients with a narrowing in their artery. Let's take 100 asymptomatic patients who go to a cardiac surgeon with a narrow coronary artery. He will advise surgery for all of them. Let's assume 50 take his advise and 50 don't. For the 50 on whom he does operate, the doctor is God. They will follow up religiously with him and sing his praises to the skies. The doctor will also believe that the reason these patients are now doing well is because of his surgical skills and that if he hadn't done the surgery, they might have died. Sadly, the surgeon has no way of following the other 50 patients who chose to ignore his advise. After 5 years, these 50 patients might be doing as well as the ones who were operated on - or even better, but the doctor has no way of comparing or finding out ! This is why these myths and misconceptions continue to be perpetuated for decades, even by well-meaning doctors !

In an excellent article, Launching the Century of the Patient, Gerd Gigerenzer and J. A. Muir Gray explain why many doctors do not understand the available medical evidence. They identify
seven “sins” which have contributed to this lack of knowledge: biased funding; biased reporting in medical journals; biased patient pamphlets; biased reporting in the media; conflicts of interest; defensive medicine; and medical curricula that fail to teach doctors how to comprehend health statistics.

As George Bernard Shaw wrote so eloquently in 1911 in The Doctor's Dilemma, " All professions are conspiracies against the laity" . This is as true today as it was then !

You can now read the transcript of the interview below the video !

Most patients find that one of the most difficult things to manage during an IVF cycle is the dreaded 2 week wait ( 2ww) after the embryo transfer. Time seems to come to a halt and you live in a state of suspended animation - a bit like Schroedinger's cat ! Am I pregnant ? Am I not pregnant ? Every ache and twinge sends you scurrying to the bathroom to check if your periods have started - and you over-interpret every signal your body sends you. Am I feeling nauseous ? Is this a good sign ? Do my breasts feel fuller than usual ? Is this just PMS ? You try to prevent your mind from playing games with you, but this is surprisingly hard to do. Every hour seems to stretch on like a day ! You obsessively compare notes with all your online IVF friends - and drive your husband batty with your interpretations and wild imaginings ! Every time he drives the car through a pot-hole, you go bonkers with the anxiety that the jolt has jarred your embryos out of their safe uterine haven and caused them to fall out !

Why do I have to wait 12 days after the embryo transfer to do a pregnancy test ? Can't I do it earlier ? After all, if I am pregnant, won't the test show this ? Aren't the new tests very sensitive ? Aren't they supposed to show a positive result even before the period is missed ?

You cheat and start doing pregnancy tests anyways - how can it hurt ? And every time it's negative, you still hope against hope ! Maybe I did it too early ? Maybe it will show up as positive if I wait another 2 days ? How can God be so unfair ? After all the shots I have taken and the pain I have suffered, I am sure he will not let me down and will give me my baby !

Remember that your embryos are safe in your uterus and that nothing you do can harm them ! If they are going to implant, they will and there's precious little you can do to influence the inefficient biological process of embryo implantation either way.

Continue taking all your medicines; leading a normal life; and please remember the Serenity Prayer.

God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

Along with watching the video, you can now also read the transcript - it's just below the video !